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Message our team and get connected to mental health care

This form will get you started with our team. It does not take the place of a diagnostic assessment or intake process. This message box is not monitored 24/7. Volumes will affect our response time. If this is an emergency, dial 911. Call 988 from anywhere in the State of Minnesota to reach the local county mental health crisis team.

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Are you a person in the child's life looking for support or are you a medical provider completing a referral? *

I am a parent or caregiver
I am a medical provider

Name of person completing the form *

First

Last

What is your relationship to the child/teen? *

At what company or organization do you work? *

Name of the child's parent or caregiver *

First

Last

Name of the child/teen you are referring *

Name of the child/teen for whom you're seeking information *

How old is the child/teen? *

Please enter a number from 0 to 18.

What is the current city of residence for the child you are referring? *

Where do you currently live? *

If your child or teen has insurance, what type of insurance coverage do they have? *

Agile
Blue Cross Blue Shield
Group Health/Health Partners
PreferredOne
Medica
UCare
United Health Group
Other coverage
My child does not have insurance

Assessment

My child acts impulsively or without concern for risk *

Not at all
Slight
Moderate
Severe

My child repeats certain behaviors or activities *

Not at all
Slight
Moderate
Severe

My child is having difficulty in school (in-person) *

Not at all
Slight
Moderate
Severe

My child is having difficulty in school (digital/distanced learning) *

Not at all
Slight
Moderate
Severe

My child’s mood shifts unexpectedly *

Not at all
Slight
Moderate
Severe

My child has thoughts, fears, or worries that make it hard for them to function *

Not at all
Slight
Moderate
Severe

My child has eating or body image concerns and this is a primary concern *

Not at all
Slight
Moderate
Severe

My child engages in negative self-talk *

Not at all
Slight
Moderate
Severe

My child experiences anger, irritability or rage *

Not at all
Slight
Moderate
Severe

My child is displaying physical aggression (hitting, kicking, throwing things) *

Not at all
Slight
Moderate
Severe

Has your child witnessed or experienced a traumatic event? *

Yes
No

Is your child engaging in any unsafe or risky behaviors? *

Yes
No
I'm not sure

Was there a significant loss in your child’s life, such as a death, transition or divorce? *

Yes
No

Has a teacher or pediatrician asked your child to complete a behavioral, emotional or developmental assessment? *

No
Yes, but we have not completed it
Yes, we had my child take an evaluation

Are you currently receiving other mental health or support services for this child?

Yes
No

If you have any other requests, information or concerns regarding your child, please share them in the box below.

Please include any psych testing, types of therapy, or any specific clinician skills/traits/identities that would be most helpful for your child or teen.

Please share any other pertinant information for the child you are referring:

Please include any psych testing, types of therapy, or any specific clinician skills/traits/identities that would be most helpful for this child or teen.

Contact Information

Phone number (initial contact will be via phone) *

Please note: the official referral requires a phone call, but email is a great starting point if it is more comfortable for you, the parent or caretaker.

Is this your phone number as the referral source, or the phone number of the child's parent, caregiver or guardian? *

This is my phone number
This is a caregiver's phone number

May we leave a message for you on voicemail at this number? *

Yes
No

Any communication with Washburn Center is private and protected under HIPPA guidelines and regulations

Email

Will you need translation services for therapy?

No
Yes

For what language would you like a translator?

What time is best for Washburn Center to reach out?

Morning
Afternoon
Either

Any communication with Washburn Center is private and protected under HIPPA guidelines and regulations

How did you hear about Washburn Center?

Is there a program that you think would be a good fit for your child?

*

I understand that I will need to fill out a Release of Information Authorization form and upload it below to complete this referral

Click here to view and download Washburn Center's Release of Information Authorization Form

File Upload *

Click or drag files to this area to upload. You can upload up to 3 files.

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Translation of this site is offered via Weglot translator. We understand there are regional differences in translations. Every effort has been made to ensure accuracy. And, we understand translations can be imperfect. Thank you for your grace.

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